To provide an overview of performance of public health services and programmes in order to provide assurance.

Apologies were received from the director of public health. The consultant in public health was in attendance to present the public health update. 

 

The director for adults and wellbeing introduced the update. Responsibility for public health services had transferred from the NHS to councils in 2013. This was a sensible decision as councils played an influential role the wellbeing of the population. There were significant synergies gained and public health brought a beneficial skill set to enable working in different ways. 

A member commented that commissioned services were just a part of public health’s work, and asked about the timing of the availability of the director of public health’s annual report. It was clarified that this would be available at the end of October.

 

The consultant in public health presented the update, focusing on commissioned services for sexual health, stop smoking, and NHS health checks. Drug and alcohol services, which had been a concern, would also be covered and the service provider, Addaction, would be represented to provide an update. 

 

Sexual health services

 

The main points highlighted in relation to sexual health services were:

•           The contract with Herefordshire Health Partnership (HHP) to provide this service commenced in December 2015

•           There were challenges faced by the new providers to find premises and establish the service, but these had been overcome and the service was now fully functional

•           The service was based on a hub and spoke model, going out to Bromyard, Ledbury and Leominster, and using GP premises, with plans to offer a late evening clinic

•           A confidential online testing service for sexually transmitted infections (STIs) was set up for over 16s, with a return rate of 72% of tests

•           Online screening had also commenced in April 2016 for 16-24 year olds with good take-up

•           Local sexual health networks were to be established and also diagnostic testing for HIV to ensure a seamless service

 

The consultant in public health clarified that the premises were on Commercial Road, Hereford and that services were being promoted via the internet, with monthly newsletters to GPs and stakeholders.  It was noted that an online presence would be more attuned to younger people. A member commented on the importance of chlamydia testing as the condition could lead to infertility. 

 

Officers added that there was a specialist health promotion officer working with the provider and this was welcomed by members. There was also work with the provider to reach schools and colleges to raise awareness.

 

Regarding the choice of locations for hubs, it was clarified that although the areas chosen were not considered to be hotspots, the figures did suggest demand for service was higher in those areas. It was also noted that people sometimes crossed over the border with Wales to access services in order to preserve anonymity. 

 

In response to members’ comments about appropriate publicity and communications, particularly with schools and colleges, it was confirmed that a guide was about to be distributed, followed by further phased information.   There was also a website available with links to social media, and the service maintained community presence such as through music festivals to raise awareness. There were also plans to extend contact with the over 50s in recognition of an increasing prevalence of STIs in that age group.

 

Regarding value for money in relation to referral and treatment pathways it was clarified that the service was being monitored and that there was close involvement with GPs to ensure that duplication was minimised.   Members commented that there was potential for fragmentation of service provision and potential for people to slip between services and not get the treatment they needed.  Commissioners would be recommending accessible opening times for the service to increase accessibility.

 

The cabinet member for health and wellbeing reminded members that it was important to not make comparisons with the previous service provision as the new service model was different.

 

A member commented that social media was an essential part of raising awareness of sexual health issues and of the services available, but added that a tried and tested way of doing this was by advertising on the insides of toilet doors as this reached more people.   Officers noted this suggestion for consideration.

 

Responding to a further comment regarding the numbers using the service in comparison with other counties, it was confirmed that there was a rise in STIs nationally and Herefordshire was in line with that rise.   Online services were helpful in close knit communities as people could be more discrete, and this contributed to a rise in uptake. 

 

A member made an observation that there had been concerns about the provider in getting the service operational and that problems such as developing suitable premises should have been anticipated early on.   Officers replied that whilst it could be difficult to predict what local conditions would impact on delivery of a service, issues were identified early on in relation to finding premises that were clinically fit for purpose.  It was not always possible for new providers to become fully operational from the very start and for some services it could take up to 18 months. The previous service was underperforming significantly and this was now being addressed by the new service and there had been some successful outcomes already. 

 

In response to a member’s question about extending services to service users’ sexual partners, it was clarified that there was a partner notification service to offer treatment, and procedures to seek consent to share information with partners. In some cases, partners did engage and accept treatment but people did not always want to share information. 

 

Stop smoking service

 

In relation to the stop smoking service, the main points were that:

•           The services were based on behavioural support and pharmacotherapy

•           In 2016, there was a 4-week quit rate of around 50% which was in line with national figures but there was room for improvement

•           Provision may extend to other service providers to improve the success rate 

•           Quitting was a difficult process so prevention in the first place was a key intervention, and there was work planned with schools on this. 

 

In response to a question from the chairman regarding the number of unfamiliar providers in the county it was clarified that providers, operating on an ‘any qualified provider’ model, could use premises to set up clinics but not all done so yet.  Responding to a further question regarding the effectiveness of treatment, the best outcomes were through a combination of behavioural support and pharmacotherapy. Vapourised nicotine, or e-cigarettes, were not used as a formal alternative to nicotine replacement therapy as such devices were not licenced, although they were regarded by many as an alternative to conventional cigarettes. It was also possible that these could be used as carriers for other, illegal, substances although evidence for this practice was limited.

 

Discussion took place regarding factors that caused relapse for people trying to stop smoking and that there needed to be choices available to tailor the support available to individuals. However, it was important to convey a clear message that it was lifestyle choices that were the killer and that it was more effective in the long term to discourage people to start smoking in the first place. The number of quitters and targeted expenditure were a consideration in ensuring services were focused on the right people. A member commented on the use of stop smoking advice during pre-natal care and it was noted that this was to be revisited as national guidance was to refer smokers who were pregnant to stop smoking services. It was concluded that, as with all services, there needed to be an evaluation of the approaches used to ensure services were targeted effectively within the available funding.

 

Members expressed concern about the procurement process for public health services. It was noted that commissioners were working with providers to ensure performance was sustained and improved and that there were suggested timescales for contract delivery and establishing governance arrangements in order to ensure service provision that was safe and effective. It was agreed to provide more information on this in response to members’ comments that procurement was critical in enabling services to be functioning earlier, and that it would be beneficial to review procurement procedures. 

 

NHS health checks

 

It was noted that the main points regarding NHS health checks were that:

•           the service had been running for the past 4 years and commissioning started in 2015 for new providers from April 2016

•           the service was provided mainly by Taurus. There were two other providers which were not yet operational as they had no access to the patient data to enable them to provide a service. Commissioners were working with GPs to look at how other providers could access the information needed to carry out the work

•           health checks were offered for the 40-70 age group every 5 years by invitation from GPs

•           uptake was 49% which was below the national target of 66% although this level was similar to other parts of the country

•           this programme was important as a way of prevention or early treatment of cardiac and other serious health issues

 

Commenting on the uptake of the service, a member observed that the statistics did not show whether there were any patterns in relation to gender or problem areas. Officers confirmed that the uptake was 60% women and 40% men, and it was agreed to provide some further data analysis.

 

Another member noted that provision of health checks was mandatory and asked whether there was any penalty for low uptake. He commented further that there had been an undertaking to provide access to information for other providers.  The consultant in public health explained that the data-sharing issue was still being resolved but that once addressed it would be a key factor in improving performance as this would enable other providers to have access to patients’ contact details in order to invite them for checks. A member commented that better partnership working was required so that information was available at the point is was needed. It was noted that these providers did not need to see patients’ full medical records, just their addresses. 

 

Commenting on the value for money of health checks, the cabinet member for health and wellbeing noted the importance of uptake by people who needed the checks most and the extent to which they acted on advice given.  A member commented that the health service should not be taken for granted and that there should be a penalty for those who did not attend their health check. Public health could provide more information on take-up rates.

 

A member asked about what provision was available to residents close to the border whose GP was in Wales. It was noted that health checks were not offered in Wales and that this could be addressed through the use of drop-in centres so that those parts of the population would not miss out. This issue was common to any screening programmes that were not offered in Wales. 

 

It was noted that in order for people to break unhealthy lifestyle choices they needed access to a range of support. It was suggested that there needed to be greater collaboration between professionals in order to provide support at the places that people frequented such as to parents at the school gate.  It was confirmed that the health checks programme was used to refer onwards and signpost people to support, but that it could be extended to housing services for example.  

 

In answering a member’s question on the process and content of health checks, the consultant in public health outlined that a percentage of the 40 to 70 years age group was invited each year on a five year cycle. The check, carried out by a nurse or healthcare assistant, included testing blood pressure, cholesterol, height weight and a diabetes check. If risks factors were indicated, the individual would be referred to the relevant service.  The member commented on the importance of using these checks to spot health conditions early to avoid picking them up incidentally during later consultations when they are more advanced.

 

Members suggested alternatives to attendance at a GP surgery for health checks, which included self-service facilities and workplace-based checking, which would reduce demand and reliance on GP surgeries.  

 

Addaction

 

The consultant in public health explained that Addaction was awarded the contract to provide treatment for substance and alcohol misuse, which commenced in December 2015. The organisation was new to the county which presented some initial issues regarding recruitment of workers and finding premises. There were still some recruitment issues but otherwise, the service was being provided in full in line with the contract.  

 

The Addaction manager presented an overview of the service. Service aims were based on a national recovery model, and in partnership with other agencies. The model was flexible to meet local need and recognised psychosocial intervention as well as prescription based treatment to address harm reduction and relapse prevention.  Support extended to families and carers, with accessible service times. 

 

In response to a member’s question regarding referral pathways and access to partner services, the manager explained that there were a number of ways that people could access the service, which included self-referral. So that the service could work with someone’s immediate motivation, there was no waiting list to see a worker.  There was joint working and engagement with stakeholders and the service was working with 2gether NHS Foundation Trust to support people with a dual diagnosis of addiction and mental health care needs. There was also a local presence for young people on a drop-in basis. Other organisations such as AA were hosted for weekly sessions.

 

A member commented on a need for buddies within communities as it was easy for people to feel tempted into relapse. It was confirmed that the service was available for support and there was a local service user group with presence in the community to provide support.   The 11 to 25 year age group was supported, including transition to adult services. Services were opening in Leominster and Ross on Wye which could be accessed by anyone within the county. This was welcomed as it was recognised that many young people did not have fixed addresses. 

 

The chairman commented on a recent visit to Addaction’s Hereford premises and asked what research had been carried out by the organisation to inform its tender for the contract.  The manager confirmed that research was carried out on the rurality of the county and on possible premises. She added that there had been difficulties with premises and with staffing which had slowed down the delivery of the service.  However, there would be three permanent premises and there was a development plan for outreach, for example in Bromyard, and use of technology such as Skype. It was important to be flexible and so there may be some home visits where there were barriers to accessing services.   

 

The vice-chairman added that the base in Leominster was positive and included a range of healthy lifestyle activities to support prevention of alcohol and substance misuse.

 

The manager summarised the composition of the current caseload. There were 384 opiate users, 168 alcohol users and 78 service users receiving non-opiate support.  She added that there was limited research on psychoactive substances, although the service had gathered some useful local statistics during its work.   There was an increase in the use of such substances and service aimed to support recovery.   There were workshops and one to one work, as well as confidential drop in sessions to support recovery.

 

The chairman acknowledged the improvements in service since the initial start-up problems and members were encouraged to visit Addaction premises.

 

In response to a question from the chairman regarding service priorities, the consultant in public health explained that some aspects of the service were mandatory and a prioritisation exercise was taking place based on the needs of the population.  He clarified that there had been no information about funding for providing additional services or for the public health grant to be based on retention of business rates. 

 

A member referred to the previous committee meeting regarding the sustainability and transformation plan (STP) and One Herefordshire and asked if there was any update given that there was a requirement to complete the commissioning process by the end of December 2016.

 

The director for adults and wellbeing summarised the latest position, which was that the local programme team was working on the draft submission, allowing one week for comments prior to submitting the STP by 21 October 2016.  It was not clear as to the status of that submission although advice from NHS England was that the plans would be subject to an assurance process after which they would be available for wider circulation.  This gave little time to agree binding contracts in December.

 

However, there was a requirement for public consultation and scrutiny despite limited time to do so before contracts were agreed.  There was an issue of urgency to alleviate financial pressures in the NHS and the expectation was that plans would have significant impact on services and therefore the NHS wished to be cautious about sharing plans that might not materialise. A tension remained between the NHS’s wish for caution and for the council’s right to scrutinise plans.

 

The chairman asserted that it was essential for the committee to scrutinise the proposals in the best interests of Herefordshire.  Members were elected to ensure that the public purse was used appropriately and effectively and there was very clear guidance available to confirm the right for proper scrutiny of NHS plans.  There was a case for a joint scrutiny meeting across the planning footprint with Worcestershire to ensure plans were appropriate and to have sight of local developments.

 

Noting the further services referred to in the public health update that had not yet been covered in the meeting, the chairman proposed a task and finish group to review in full the mental health services for children and young people. She observed that there had been a positive presentation by the main provider, 2gether, but this did not represent the full picture. 

 

Referring also to the Healthy You programme pilot for diabetes prevention discussed at the previous meeting, it was agreed to circulate more information about the level of commitment required for participants as it was considered to be unrealistic. It was important to provide feedback about this, given that despite the significant number of people at risk of developing type 2 diabetes, only 70 people had taken up the service. 

 

The chairman thanked public health officers and Addaction for attending the meeting.

 

RESOLVED

THAT:  

(a)        performance and improvement action of public health programmes and service be noted; 

(b)       the committee undertake a review of spending across all public health services;

(c)        there be an evaluation of stop smoking service provision to assess value for money;

(d)       an action plan be developed by public health to increase uptake of health checks, including consideration of the provision of clinics in accessible locations such as workplaces, and of self-service health checks; and

(e)        Addaction be asked to provide a further service update in 6 months’ time.